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SOC246H1 (20)

Soc aging- Class 11 reading 2.doc

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University of Toronto St. George
Markus Schafer

Journal of aging & social policy Re imagining nursing homes: the art of the possible introduction  good long term care requires integrating personal care, housing and medical care – succeeding on all three levels is rare – also in nursing homes  efforts have been made to improve Nhs  eden alternative to humanize them and then the greenhouse to redesign themselves  culture change emphasize patient centeredness and staff empowerment Origins of NH care (mssin)  LTC is not expected to produce a better health or functional outcome- it sucesss is measured by slowing the rate of decline in both physical function and quality of life  some argue that NH residents are unable to appreciate their environment because they live iwht dementia but most pesron with dementia are very sensitive to environment- many peopelw ith dementia enter an NH because their informal caregivers can no longer tolerate the demands of such caregiving  but some can even do well on their own with minimial checking – the absence of active caregiving may reduce the frequency of rage reaction  the underlying assumption of dementia care deserve careful reconsideration  NH has emerged an efficient way of packaging housing and personal care  some are cheaper than comparable level of care delievered the community  home and community based waiver programs spend less per client served than NH care would cost but they also serve a generally less disable population  important to distinguish efficiency from simple costing less  efficiency implies achieving some comparable level of effectiveness at a lower cost  the balance between the three elements – personal care and room and board as well as housing were never carefully considered  NH became the symbol of LTC and has become the policy touchstone  LTC policy were cast in terms of NHs and alternatives to them  major programs are used to transition people from Nhs or interdicting them en route and analyses of NH residents who do not need NH level of acre  at least two different perspecive on LTC effect policy decisions  one camp favors what has been called the continuum of care – people should be sorted by their needs in care types that are designed to meet those needs – as the client condition changes so woudl the approprate type of are and will be relocated  one falls under the aging in place banner – which holds that person with widely varying needs can be treated in the same place - the nature and intensity of treatment can be altered to fit the circumstance and the same basic care can be given in multiple locations Role ofAdvocacy  institutional care has for decades been shunned by younger people with disabilities- whose advocates have demanded that such institutions be closed and service be relocated to the community for a more normalize existence  active effort at rebalancing care,substantial effort has gone to seek ways to rehabilitate the NH  frail elder lack political constituency there is no great social outcry for reform  baby boomers are not proactive consumer advocated for their parents that some had hoped for  “” perhaps they are overwhelmed by the caregiving task it is hard to form a group to figt for the frail elderly  most caregivers become involved during the fray but are quick to put it behind them once the older person dies  the sustained advocacy for the younger person with disabilities has yet to emerge for older person and little evidence that younger people are willing to join forces with the elderly Role of Regulations  long history of abuse and concerns about NH residents  frail older people are termed vulnerable elders are considered to need a great deal of protection  due to its history a strong strict regulations may not serve well today because a strong commitment to strict reguations makes more progressive and creative care difficult  regulatory framework provides a floor for quality but also a ceiling  some suggest the problem lies less in the regulations than in the failure to enfore them but this is common problem with regulatory strategy which leads to prolonged litigation and settlemtn  regulation are dominated by those being regulated  Nhs have been strongly influenced by various professional each arguing tha tmore of those service are central to good care  the emphasis is placed on structure and process of care – at the expense of outcomes which should include quality of life Attempts at innovation  quality improvements only solve small pieces of the problem not the central problem  projects like the greenhouse and small house demonstates ways of making Nhs morelivable and person centered bu they perpetuate many of the unwanted aspect of such caregivers  improved institutions are half solutions  culture change promise new directions implying empowerment staff or resident but they are best repairs to a flawed infrastructure and at worse simply old win in new bottles  “” this improvement is not supported by evidence of real impact  good place to start is by asking what peple really want from organized LTC  People seck LTC when they can no longer cope on their own  personal assistance from family has been exhausted  “” they can no longer maintain a houshold the need care but not at the cost of autonomy and dignity. Those who are cognitively intact still want to control their own lives and hteir own routines and do the things they enjoy  such planning cannot occur in a vaccum but it will be strongly influenced by cost constraints either from personal finances or government coverage.  The challenges is to develop funding that yields desired types of caregiverswhile pay for performance has been challenged, aligning payment with desired practice makes sense  the pressure to spend public funds are different from people's willingness to spend their won money  when pressed to use their own resources, older people are likely to make do and hence stay in their current situation, even when better options are available Building blocks of LTC  LTC is based on three elements: personal service ( assistance required to help people perform basic task, including supervision for those who have cognitive impairments); housing; and medical ( actually a range of clinical care service provided by a variety of disciplines) service ( directed at chronic conditions)  each of these buildings blocks represent a spectrum of need  NHS does not address any of these especically well  the three are the goals  the basic assumption of NH care is the price of personal care is accepting institutional living – must be challenged  it is bening challenged as the use of NH declines  the first step would be to rescind the notion of Nhs and instead begin with the premise that all care is home care – simply changing the public payment formula to separate payment for service from those for room and board  the latter would need to be handled as they are for all person regardless of age or disability level; peoplw would use thier own funds to cover such cost with supplements as necessary  people living in quite varied levels of comfort would receive the same care service  Nhs would instantly find themselves needing to compete on the basis of offering livable conditions; they could no longer get away with the enormous restrictions they impose on individual freedom and living situations  uncoupling payments offer opportunities for more creative packaging; it also present problems  accountablilty may become more difficult if various organizations are involved in separate service – overarching accountable entity will be needed  separate payment may make integrated coverage and de facto cross-subsidy more difficult if payers limit their coverage to only specified elements of care.  The implication of NH closure are significant- it could not occur all at once without creating akor disruption  some providers are taking active steps to diversify and close best by converting multiple occupancy rooms into single- occupancy
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